Factors influencing implementation of digital cardiac rehabilitation: A qualitative analysis of health workers perspectives

Introduction

Secondary prevention is an important strategy to reduce the burden of cardiovascular disease (CVD), which accounts for almost one third of all deaths globally^1,2. Comprehensive secondary prevention programmes, which include cardiac rehabilitation (CR), can reduce CVD mortality, recurrent CVD hospital admissions, and improve overall quality of life^3,4. However, CR is underutilised, with barriers including low referral rates, lack of access and limited capacity, among others^5,6. Notably, the majority of eligible patients do not meet guideline recommended lifestyle and risk factor targets^7,8. Digital cardiac rehabilitation (CR) interventions such as telemedicine, mobile health (smart phone apps, wearables, text messaging), web based applications and virtual reality are emerging as a promising solution to improve uptake and participation⁵. There is growing evidence to show similar efficacy on important endpoints such as LDL cholesterol, exercise capacity, and medication adherence, which are comparable to in-person, centre based rehabilitation^9–11.

Despite the potential benefits of digital CR interventions, their adoption into routine clinical practice has been slow and most do not reach large implementation scale^12,13. Even during the Coronavirus disease-2019 (COVID-19) pandemic, when technology was urgently needed and embraced, less sophisticated technologies such as the telephone were most widely used to deliver remote CR¹⁴. Barriers to the implementation of digital CR are complex and exist at the health system, patient and health workforce level¹⁵. Health workers play a pivotal role in bridging the gap between innovative solutions and patient care, ultimately influencing whether a new technology succeeds or fails^16,17. Therefore understanding their experiences is an important part of digital CR evaluation¹⁷. However, in comparison to patients, health worker related barriers and facilitators to digital CR¹⁸, have been less frequently described with one of the first systematic reviews in this field recently being published¹⁵. While this review included 20 studies, from 5 countries, the majority of studies were surveys (n=13) with the remainder (n= 7) focusing on implementation of home-based (n=4), hybrid (combined in person and home based or digitally enabled models, n=1) and virtually delivered interventions (n=2)¹⁵. Given that the effectiveness of digital interventions are highly dependent on context¹⁹, there remains a need to expand the number of implementation studies focusing on health workers perspectives of specific digital CR interventions. Insights into these perspectives are critical for optimising implementation strategies for digital CR, to enable scale up and translation into clinical practice.

Having already examined the clinical outcomes of “MySláinte” a digital CR intervention delivered during the COVID-19 pandemic²⁰, we conducted a nested qualitative study, to understand what factors influenced implementation of this programme from the perspective of health workers. The aims of this qualitative study were to a) conduct a post implementation evaluation of the barriers and facilitators to “MySláinte” and b) to identify potentially salient factors to inform the future implementation of digital CR. We use the term “health workers” to describe the roles of both health care professional (HCPs) and those in administrative and managerial positions.

MySláinte (Gaelic for MyHealth) was developed by Croí, an Irish Heart and Stroke patient organisation in response to the need to provide patients with access to comprehensive CR during the COVID-19 pandemic. The process of developing MySláinte, together with the key intervention features and clinical outcomes have been previously reported²⁰. In brief, the core components included lifestyle modification, risk factor management, and psychosocial and behavioural change support. Patients received access to a bespoke web-based platform, a Fitbit™, a home blood pressure monitor, and were invited to attend weekly, online group-based supervised exercise sessions and educational workshops.

Methods

Results

Of the 15 health workers invited to participate, 14 (93%) responded. Interviews lasted on average 46 minutes (range 32-50 minutes). Participants included Croí HCPs (nurse prescriber, dietitian, physiotherapist) an administrator and chief executive officer (CEO) (n=5), and hospital cardiology and CR nurses (n=9). Characteristics of participants are outlined in Table 2.

Factors influencing implementation of the MySláinte programme operated across the five CFIR domains: (1) Innovation; (2) Outer Setting; (3) Inner Setting; (4) Individuals; and (5) Implementation Process (Figure 1). Most factors acted simultaneously as barriers and facilitators, and while many acted independently in influencing implementation, some acted in combination. Through our analysis, we developed a matrix combining health workers perceived barriers and facilitators to implementation. Supported by sample quotes, this matrix also includes considerations to guide the future implementation of digital CR (Supplementary file 3: https://osf.io/z9msx/). The following section provides a narrative summary of the most commonly occurring factors and how they manifested across the five CFIR domains. HCP perspectives on considerations for future implementation efforts of digital CR are incorporated throughout.

Figure 1. Factors influencing implementation of Croí MySláinte across multiple levels.

Note: +, facilitators: -, barriers. Outer Setting = the extrinsic ecosystem, in which the Inner Setting exists; Inner Setting = the setting in which MySláinte was implemented; Individuals = roles and characteristics of those involved in implementing, delivering and/or receiving MySláinte; Innovation = the Croí MySláinte programme; Implementation Process = activities and strategies used to implement MySláinte.

This figure has been reproduced with permission from CFIR 2.0. Adapted from Damschroder, L. J., Reardon, C. M., Widerquist, M. A. O., et al. (2022). The updated consolidated framework for implementation research based on user feedback. Implementation Science, 17, 75. https://doi.org/10.1186/s13012-022-01245-0. Image adapted by The Center for Implementation, © 2022. Version: V2024.01. https://thecenterforimplementation.com/toolbox/cfir

Discussion

Using the CFIR, this study examined health worker perspectives of factors influencing implementation of MySláinte, a digital CR intervention delivered during the COVID-19 pandemic. Established areas of focus for implementation of digital health interventions (DHIs) include: intervention characteristics and technical factors, individuals (workforce and patients), the healthcare ecosystem and the broader extrinsic ecosystem within which they operate^19,28. Consistent with recent systematic review and scoping review evidence^13,15,29, we identified barriers and facilitators to implementation across all of these areas, including the implementation process which often receives insufficient attention in digital technology implementation frameworks¹⁶. To our knowledge, this is the first study to explore health worker perspectives of digital CR using the CFIR. While most factors influencing implementation of MySláinte operated independently, many also acted in combination. For example, strong partnerships and connections at the outer setting between organisations combined with the programme features (e.g., inclusion of the MDT and recommended CR core-components) and evidence base increased health worker confidence, and subsequent engagement in implementation. Consistent with previous studies^16,22,29, these findings demonstrate the dynamic inter-relationships that exists between factors. Therefore, understanding these inter-relationships is essential to optimising implementation of digital CR²².

The perceived usefulness of technology has been identified as one of the most common facilitators to implementation of DHIs among health workers^13,29. In keeping with these findings, the perceived value of MySláinte in providing patients with essential CR, whilst also addressing CR service waiting lists, motivated health workers to engage in implementation. Engagement was further enhanced by organisational leadership support and a culture of patient centeredness, both established predictors of implementation success^21,22. These findings reaffirm that implementation of DHIs is a social process which is influenced by the values, mind-set and engagement of individuals involved, including local champions^16,30. Health workers identified multiple benefits associated with MySláinte (e.g., increased accessibility and convenience for patients) which superseded in person CR programmes. However, health workers acknowledged that there was a trade-off between these benefits and perceived programme disadvantages, for example lack of peer support. In line with WHO recommendations, these findings emphasise the need for the “value” of digital CR to be clearly communicated, including benefits for patients, health workers, and health systems as well as the rationale for why they are superior to the current standards of care^17,31.

The implementation of MySláinte required a significant shift in how health workers delivered CR care with new work practices and care pathways needing to be established. Not unique to MySláinte, the rapid transition to remote care during the COVID-19 pandemic necessitated the use of an existing platform Moodle, which was not appraised as optimal for CR delivery^14,32. This led to an increased workload, which added to the complexity of delivering CR care. Increased work and altered workflows are frequently cited barriers among health workers to DHI implementation²⁹, including those specific to CR¹⁵. To address these barriers, there is a need to involve health workers in all stages of the design, development and implementation of digital CR^19,33,34. Indeed, in a recent overview of systematic reviews of HCP barriers and facilitators to DHIs, involving health workers in DHI design was identified as a common facilitator to utilisation of DHIs across all 108 primary systematic reviews²⁹. Beyond the usability of the digital platform, health workers identified challenges regarding its interoperability in the context of a health system where information and communications technology (ICT) is not standardised or harmonised. Not limited to our study, interoperability of DHIs is a global problem^19,34, which requires implementation of national data interoperability standards in order to be addressed³⁵.

Similar to recent systematic review findings by Ferrel-Yui et al.¹⁵, workforce capacity issues including HCP-patient ratios and time to deliver in the context of the return to in-person programmes acted as barriers to implementation. Frederix et al.³⁶, argue that DHIs need to be blended into current practices, rather than being an “add on” to existing delivery models. Ultimately, implementation of digital CR requires dedicated resources, including staff who are equipped with skills and competencies in digital health delivery¹². Our findings show that limited experience and training in digital health was an obstacle to implementation with similar barriers reported internationally^19,37. These findings point to the need for greater integration of digital health competencies into the undergraduate and postgraduate curriculum as well as real-time, on the job training and support^16,38.

Health workers reported uncertainties regarding patient suitability for virtual care; these related to low digital literacy levels, limited access to technology and broadband, and the patient’s CVD risk profile. These findings are not surprising given that digital CR studies tend to focus on homogenous populations, where the majority of participants are male, and younger (<63 years)^11,39. To determine which patients may be best served by digital CRs, future research needs to be inclusive of oppressed and minoritized groups, e.g., people of colour, women, and the elderly. Furthermore, we believe these uncertainties could be addressed by conducting a rigorous assessment of patient needs, including their digital literacy and access to technology and broadband, in advance of DHI deployment. This will ensure that adequate supports are in place to enhance participation¹⁹.

While there was widespread agreement that patients should be offered digital CR beyond the pandemic, referring health workers expressed safety concerns about delivering exercise remotely to high CVD risk patients. These safety concerns are mirrored internationally^14,40, and could be addressed by greater use of remote monitoring technologies and sharing of good practice for the use of digital CR in high-risk patients^5,40. Notwithstanding the importance of patient preference, health workers identified that hybrid CR, which combines in-person and remote components, could be a promising opportunity to broaden CR access⁴¹. However, essential to this approach is effective integration of care between digital CR and in-person CR, and further research is required to understand how to optimally achieve this.

We observed similarities between our findings and the recent study by Kenny et al.⁴² exploring patient experiences of MySláinte and a similar digital CR intervention. Specifically, health workers efforts to engage and support patients through developing interpersonal relationships, for example being more accessible and the provision of technical support, increased engagement. These findings suggest that DHIs do not necessarily compromise the patient-heath worker relationship, a commonly held perception among health workers⁴³. Furthermore, health workers identified that limited opportunities for peer support negatively affected patient engagement. A challenge, which health workers suggested, could potentially be overcome through a hybrid CR delivery model. Finally, health workers identified the importance of partner and family support in engaging patients to use the technology, a factor which is known to improve DHI use by patients^15,42.

Conclusion

With an increasing emphasis being placed on offering patients a range of CR options, successful implementation of DHIs is contingent upon a comprehensive understanding of the challenges and opportunities faced by health workers. Leveraging on the practical experiences of implementing a digital CR intervention during the COVID-19 pandemic, we identified a number of factors which may help inform future strategies to enable scale up and integration into clinical practice. Findings from this study highlight how factors influencing implementation of digital CR are interconnected. Therefore, multi-level implementation strategies are required if the true potential of digital health in improving equitable CR access, participation and patient outcomes is to be realised.

Ethics and consent

Ethical approval was obtained from the Galway Clinical Research Ethics Committee (Ref. C.A 2689) on the 27^th of August 2021. Informed written consent, was obtained by providing participants with a description of the research along with a participant information sheet.